Recurrent endotracheal tube cuff rupture and subsequent right upper lobe atelectasis secondary to an occult nasal septal spur in a 31-year-old female: a case report

Introduction

Background

Nasotracheal intubation (NTI) is a fundamental airway management technique widely utilized in otorhinolaryngologic, maxillofacial, and oral surgeries. Its prevalence is attributed to its ability to provide an unobstructed surgical field in the oral cavity, pharynx, and larynx, as well as its superior patient comfort compared to orotracheal intubation (1,2). Despite its widespread application and generally favorable safety profile, NTI is associated with a spectrum of potential complications. These include epistaxis, endotracheal tube (ETT) cuff rupture, nasal mucosal injury, bacteremia, and, in rare instances, severe sequelae such as retropharyngeal abscess (1,2). Among these, ETT cuff rupture warrants particular attention, as it can result in hypoventilation, an increased risk of aspiration, and the need for unplanned reintubation (3).

Nasal anatomical variations significantly elevate the risk of NTI-associated complications. Nasal septal spurs—localized bony or cartilaginous projections arising from the nasal septum—represent a common anatomical variation, with an estimated prevalence of up to 80% in the general population (4,5). Importantly, many septal spurs remain covered by intact nasal mucosa, rendering them clinically occult and difficult to detect during routine anterior rhinoscopy (6). While previous studies have acknowledged the association between nasal septal spurs and ETT cuff damage during NTI (3,7), the current literature has insufficiently addressed the risk of severe downstream complications resulting from such injuries, including significant airway hemorrhage, hypoxemia, and lobar atelectasis.

Rationale and knowledge gap

Previous case reports have documented ETT cuff ruptures during NTI in patients with nasal septal spurs or other structural deformities. For instance, Kaloria et al. (3) highlighted recurrent cuff ruptures during nasopharyngeal intubation attributed to nasal anatomical variations. Similarly, Jang et al. (7) recently reported a case of difficult NTI caused by a nasal bony spur, underscoring the necessity of thorough preoperative airway assessment. However, these reports predominantly focus on ETT cuff damage as an immediate complication, with limited detailed exploration of the subsequent respiratory sequelae, such as hypoxemia and secondary atelectasis. Furthermore, the challenges of NTI posed by occult nasal septal spurs remain underappreciated, leading to situations where the anatomical anomaly is only identified retrospectively after complications have already occurred, as illustrated in the present case.

Objective

We report a unique case of a 31-year-old female patient who, during NTI, experienced an ETT cuff rupture caused by an undiagnosed nasal septal spur, which subsequently triggered airway hemorrhage, right upper lobe atelectasis, and severe hypoxemia. We provide a detailed description of the clinical presentation, management, and patient outcomes, contextualized within a comprehensive review of the relevant literature. We present this article in accordance with the CARE reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-2026-1-0005/rc).

Case presentation

Chief complaint

A 31-year-old female patient presented to our institution with a several-month history of bilateral temporomandibular joint (TMJ) pain.

History of present illness

The pain was attributed to a previous orthognathic surgery and subsequent condylar resorption, necessitating further surgical intervention. The patient had a history of mild intermittent asthma and snoring, but no prior diagnosis of sleep-disordered breathing (SDB).

Medical and surgical history

The patient’s surgical history included multiple procedures under general anesthesia, encompassing facial cosmetic and maxillofacial surgeries. Her previous anesthetic courses were uncomplicated, devoid of any serious adverse events or documented nasal spurs. Preoperative airway assessment revealed normal findings (Mallampati class I–II, with adequate mouth opening and thyromental distance). Routine preoperative evaluation did not suggest any nasal pathology, and specific otorhinolaryngological examinations (e.g., anterior rhinoscopy, nasal endoscopy) were omitted.

Preoperative physical examination

Preoperative vital signs were within normal limits: blood pressure 118/72 mmHg, heart rate 76 beats/min, respiratory rate 16 breaths/min, and SpO₂ 98% on room air. The systemic physical examination was unremarkable.

Anesthetic management

Induction of general anesthesia proceeded as planned. Premedication consisted of midazolam (2 mg) and penehyclidine (0.5 mg), administered 30 minutes prior to induction. Anesthesia was induced with propofol (140 mg), fentanyl (0.1 mg), hydromorphone (1 mg), lidocaine (150 mg), and rocuronium (30 mg).

Based on a clinical assessment of nasal patency, a size 7.0 mm nasal reinforced Ring-Adair-Elwyn (RAE) tube was advanced through the left naris under fiberoptic bronchoscopic guidance. The tube passed without apparent difficulty, and no significant resistance was encountered during advancement. However, immediately following placement, inadequate inflation of the ETT cuff was noted, raising suspicion of a cuff rupture. Upon removal of the initial ETT, blood was observed at the tube tip, indicating mucosal trauma and suggesting that the cuff had been lacerated by a bony spur in the left nasal passage.

Subsequently, a decision was made to exchange the tube for a size 6.0 mm nasal RAE using an 11-Fr airway exchange catheter. Despite successful placement, the patient remained inadequately ventilated. Shortly thereafter, progressive hypoxemia developed, with the SpO₂ dropping to 85%. The nasal tube was removed, and bag-mask ventilation was initiated, which improved oxygenation with the SpO₂ rose to 90%. Orotracheal intubation was then performed using a size 7.5 mm ETT with the assistance of a GlideScope. Nevertheless, despite the administration of 100% FiO₂, the SpO₂ plateaued in the range of 85–90%.

Physical examination during the event

Pulmonary auscultation revealed markedly diminished breath sounds over the right upper lung field. No tracheal deviation was noted.

Radiological findings

An emergent portable chest radiograph demonstrated right upper lobe atelectasis. No preoperative chest imaging was available for comparison, and the patient had no known history of pulmonary disease.

Bronchoscopic findings and interventions

Emergent flexible bronchoscopy was performed, revealing a dark red blood clot obstructing the right main bronchus. The clot was suctioned from the right upper lobe, resulting in an immediate improvement in oxygenation. Following clot extraction, the patient’s hemodynamic status remained stable, and no further desaturation episodes occurred.

Surgical outcome

Once the patient was stabilized, the scheduled TMJ surgery proceeded uneventfully. Intraoperative vital signs remained within normal limits throughout the procedure, with no further complications encountered. No recurrent nasopharyngeal bleeding was observed during the surgery or at the time of extubation. A pre-extubation computed tomography (CT) scan was obtained, confirming improved aeration of the right lung. The chronological timeline of this case is summarized in Figure 1.

Figure 1 The process of procedure. CT, computed tomography; RAE, Ring-Adair-Elwyn; TMJ, temporomandibular joint.

Postoperative course

The patient was transferred to the post-anesthesia care unit (PACU) in a stable condition and was subsequently discharged home without further pulmonary complications. A 3-month postoperative outpatient follow-up confirmed the absence of recurrent respiratory symptoms or sequelae related to the intraoperative event.

Final diagnosis

The final clinical diagnoses were:

• Right upper lobe atelectasis secondary to blood clot obstruction during NTI;
• Suspected ETT cuff rupture caused by an occult nasal septal spur, based on clinical findings including immediate cuff dysfunction and evidence of bleeding upon tube extraction.

Ethics

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written consent for submission and publication of this case report including imaging and associated text has been obtained from the patient in line with Committee on Publication Ethics (COPE) guidance. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Principal findings

We report the case of a 31-year-old female patient who underwent an uncomplicated NTI during her initial surgery but experienced anomalous ETT cuff deflation during a repeat NTI several years later. The anesthesia team suspected that an occult mucosal-covered nasal spur had punctured the ETT cuff. Despite exchanging the ETT, inadequate ventilation persisted, and the patient’s oxygen saturation precipitously dropped to 85%. Subsequent attempts at orotracheal intubation failed to improve oxygenation. Pulmonary auscultation revealed absent breath sounds over the right upper lung field, and a chest radiograph confirmed atelectasis. Emergent bronchoscopy identified airway mucosal hemorrhage and blood clots, one of which totally occluded the right main bronchial orifice. Following clot extraction, the patient’s oxygenation improved dramatically, and no further complications ensued.

Strengths and limitations

A primary strength of this case report is its detailed, chronological documentation of a rare but clinically significant cascade of complications, ranging from the initial cuff rupture to the development and subsequent resolution of lobar atelectasis. The bronchoscopic image (Figure 1) vividly illustrates the obstructing blood clot, while serial radiographic imaging (Figure 1) captures the dynamic progression of the atelectasis. Furthermore, by integrating a relevant literature review, this report provides a robust platform for discussing preventive and intraoperative management strategies.

However, certain limitations must be acknowledged. The associations observed in this single case may lack generalizability. Additionally, the diagnosis of a nasal septal spur remains presumptive in this instance, as postoperative confirmatory modalities, such as nasal endoscopy or CT, were not obtained. Finally, while the 3-month follow-up period was adequate for assessing early recurrence of respiratory symptoms, it may be insufficient to definitively rule out long-term sequelae, such as nasal synechiae or chronic rhinosinusitis.

Comparison with similar studies

Previous case reports have documented ETT cuff ruptures during NTI in patients with nasal anatomical abnormalities. Kaloria et al. (3) described recurrent cuff ruptures during nasopharyngeal intubation, emphasizing the critical role of anatomical variations and careful tube selection. Similarly, Jang et al. (7) recently reported a difficult NTI caused by a nasal bony spur, highlighting the necessity of identifying such deformities preoperatively.

Our case diverges from these previous reports in several pivotal aspects. In the majority of documented cases, nasal spurs were either detectable during preoperative assessment or easily identified intraoperatively (3,7). In contrast, the spur in our patient was likely enveloped by intact nasal mucosa, rendering it an occult anomaly undetectable by direct visualization (6). Furthermore, while previous reports have predominantly focused on ETT cuff damage as the primary complication, our case meticulously delineates the secondary chain reaction: epistaxis leading to clot formation, which ultimately culminated in lobar atelectasis and severe hypoxemia. This progression from a mechanical airway insult to a parenchymal pulmonary complication is inadequately documented in the existing literature. Notably, our case demonstrates the pivotal diagnostic and therapeutic utility of bronchoscopy in managing such a multifaceted complication.

Interpretation of findings

Mechanical mechanism: the “railroad effect”

The “railroad effect” refers to the advancement of an ETT over a guiding device, such as a flexible bronchoscope, into the trachea. Although conceptually straightforward, this maneuver involves imperfect alignment. The ETT is typically wider than the guiding device, creating a gap that prevents the ETT tip from tracking precisely along the centerline. Consequently, the bevel or tip of the ETT can impinge upon airway structures (8). During NTI, the advancement of the tube against a sharp intranasal structure can cause cuff laceration (9), while friction between the ETT and the nasal cavity can induce mucosal trauma, triggering epistaxis (10).

Physiological mechanism: the Bernoulli principle and atelectasis formation

The distal migration of the blood clot into the right upper lobe bronchus, resulting in atelectasis, may be elucidated by the Bernoulli principle. This hemodynamic principle states that as the velocity of a gas flow increases, the internal pressure within that flow decreases. This localized pressure drop can generate a suction effect, entraining blood or clots into the airstream and propelling them distally. Stagnation of blood in the distal airways promotes further thrombosis, ultimately occluding the bronchus and inducing atelectasis (11,12). The rapid onset of hypoxemia in our patient aligns with the profound right-to-left intrapulmonary shunting physiology characteristic of sudden lobar atelectasis.

Clinical decision-making based on current guidelines

We critically analyzed our management of this case in the context of the 2025 Difficult Airway Society (DAS) guidelines for the management of unanticipated difficult intubation in adults (13). These guidelines strongly emphasize “first-pass success” and the “proactive prevention of failure”. In our case, upon discovering the damaged initial cuff, the decision was made to exchange the ETT using a tube exchanger while utilizing the same naris. Viewed through the lens of current guidelines, a more prudent approach might have involved a rapid transition to an alternative strategy, such as immediate orotracheal intubation or the use of a smaller-diameter tube equipped with a cuff protector. The DAS guidelines advocate that if two intubation attempts are unsuccessful or if any signs of difficulty arise, clinicians should cease repeated attempts and prioritize optimization and alternative plans. Although we ultimately transitioned to orotracheal intubation following two failed nasal attempts, the repeated nasal instrumentation likely exacerbated the epistaxis and subsequent clot formation. Therefore, early recognition of difficulty and swift pivoting to alternative strategies are paramount for patient safety.

Implications and necessary actions

Based on this case and a review of the literature, the following evidence-based management strategies are recommended for clinicians performing NTI:

• Preoperative assessment: for patients scheduled for elective NTI, particularly those with symptoms suggestive of nasal obstruction, preoperative nasal endoscopy or radiological imaging should be strongly considered.
• Intraoperative preventive measures: the use of smaller-diameter ETTs can mitigate trauma. When nasal anatomical anomalies are suspected or difficulty is encountered during NTI, clinicians may consider the “sheath technique” described by Benoit et al. (14) to prevent cuff rupture. This technique involves covering the ETT cuff with a protective sheath during nasal passage, which is then removed once the tube is in situ. If resistance is met during intubation, forceful advancement must be strictly avoided; alternative approaches, such as using the contralateral naris or converting to an orotracheal route, should be implemented.
• Complication management: when cuff damage is suspected or confirmed, particularly in the setting of concurrent hypoxemia, emergent bronchoscopy should be strongly considered. As demonstrated in our case, bronchoscopy serves a dual diagnostic and therapeutic purpose, allowing for direct visualization of hemorrhage, identification of blood clots, and immediate suctioning. While airway exchange catheters are useful for ETT replacement, they must be used with extreme caution in the presence of airway bleeding to prevent further trauma.

Future prospective studies are warranted to accurately ascertain the incidence of occult nasal septal spurs in the surgical population and to systematically evaluate the efficacy of various ETT cuff protection strategies.

Conclusions

Cuff rupture during NTI can lead to severe complications, necessitating careful management. To address the risks associated with cuff rupture, various complementary strategies have been employed to reduce its complications. However, more effective methods are urgently needed to protect the cuff and enhance airway management during NTI, particularly in patients with nasal spurs.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-2026-1-0005/rc

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-2026-1-0005/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-2026-1-0005/coif). H.M. serves as an unpaid editorial board member of Journal of Oral and Maxillofacial Anesthesia from February 2026 to December 2027. J.P.W. serves as the unpaid Deputy Editor-in-Chief of Journal of Oral and Maxillofacial Anesthesia from March 2025 to February 2027. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written consent for submission and publication of this case report including imaging and associated text has been obtained from the patient in line with COPE guidance. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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